Inspection visit

Health inspectionJuly 18, 2024

ELIZABETHTOWN NURSING AND REHABILITATIONCMS #39584419 citations on this visit

19 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 19 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0575 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observation and staff interview, it was determined that the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies, advocacy groups, and a statement that the resident may file a complaint with the State Survey Agency concerning suspected violations of state or federal nursing facility regulations for one area observed (facility bulletin board). Findings Include: An observation of the facility's bulletin board, containing information for resident review, on July 15, 2024, at 11:04 AM, revealed no information listing resident advocacy groups, the State agency information, including mailing and email addresses, telephone numbers, and statements regarding the resident's right to file complaints with State and Federal agencies. An interview with the Nursing Home Administrator, on July 17, 2024, at 1:40 PM, revealed the required information is now posted and accessible for resident review. 28 Pa. Code 201.14 (a) Responsibility of licensee Page 1 of 26 395844 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observations and staff interview, it was determined that the facility failed to ensure its residents the right to examine the results of the most recent survey and that those results are posted in a place readily accessible to its residents for one area observed (facility lobby). Residents Affected - Few Findings Include: An observation in the facility's lobby, on July 15, 2024, at 10:32 AM, revealed the facility's survey results book in an area accessible only by using a code to gain entrance and exit. Observations in resident areas, beyond the locked lobby area, revealed no survey books for resident review in the dining area, the resident common area, the nurses' station, or the designated activities area. An interview with the Nursing Home Administrator, on July 17, 2024, at 1:38 PM, revealed the facility's survey results book is now accessible in resident areas and confirmed the book should not only be present in the facility's locked area. 28 Pa. Code 201.14 (a) Responsibility of licensee 395844 Page 2 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on facility policy review, clinical record reviews, and staff interview, it was determined that the facility failed to offer the option to formulate an advance directive, as evidenced by utilization of only the POLST (Pennsylvania Orders for Life-Sustaining Treatment) and no documentation of the resident's choices pertaining to advanced directives or documenting how the resident was informed of his or her right to develop a living will or advance directive for four of 35 records reviewed (Residents 1, 20, 33, and 45). Findings include: The facility's admission packet referring to the advance directive section stated, . if the resident has a health care directive, he or she must provide a valid executed original advance directive to the Nursing Home Administrator (NHA). There is no indication that residents are offered the opportunity to formulate an advance directive. A review of Resident 1's clinical record failed to include a discussion regarding the opportunity to formulate an Advance Directive. There was no Advance Directive/Living Will present in the clinical record. A review of Resident 20's clinical record failed to include a discussion regarding the opportunity to formulate an Advance Directive. There was no Advance Directive/Living Will present in the clinical record. A review of Resident 33's clinical record failed to include a discussion regarding the opportunity to formulate an Advance Directive. There was no Advance Directive/Living Will present in the clinical record. A review of Resident 45's clinical record failed to include a discussion regarding the opportunity to formulate an Advance Directive. There was no Advance Directive/Living Will present in the clinical record. An interview with the NHA and Director of Nursing on July 18, 2024, at 9:30 AM, revealed the facility was unable to locate any additional documentation of those Residents being offered information regarding the formulation of an Advance Directive or Living Will at the time of admission or during their stay. 28 Pa. Code 201.18(b)(1)Management 395844 Page 3 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on document review and staff interviews, it was determined that the facility failed to ensure each resident is periodically informed of any charges for services not covered under Medicare for two of three residents reviewed at the end of a Medicare stay (Residents 1 and 148). Residents Affected - Few Findings Include: A review of Resident 1's Skilled Nursing Facility Beneficiary Notification Review form revealed the last covered day of Medicare A coverage on April 30, 2024. A review of the facility-provided Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form (SNF-ABN), revealed Resident 1 would no longer receive Medicare covered therapy services after April 30, 2024, and the estimated cost of those non-covered services was not provided to Resident 1 or her responsible party. A review of Resident 148's Skilled Nursing Facility Beneficiary Notification Review form revealed a last covered day of Medicare A coverage on February 17, 2024. A review of the facility-provided SNF-ABN form revealed Resident 148 would no longer receive Medicare covered therapy services after February 17, 2024, and the estimated cost of those non-covered services was not provided to Resident 148 or her responsible party. An interview with the Nursing Home Administrator on July 16, 2024, at 2:02 PM, revealed the facility will begin informing residents of the cost of non-covered services, and confirmed residents and/or their representatives have the right to be informed of those costs. 28 Pa. Code 201.14 (a) Responsibility of licensee 395844 Page 4 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, document review, policy review, and staff interviews, it was determined that the facility failed to make prompt efforts to resolve resident grievances for two of 10 grievances reviewed, and failed to post in prominent locations the contact information of the identified Grievance Official, including the name, business address (mailing and email), and business phone number in one facility area observed (facility bulletin board). Findings Include: A review of the facility's policy, titled Resident and Family Concerns and Grievances Policy and Procedure, dated 2022, defines its purpose as To provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations. The policy continued, The Facility will provide the resident with a written Grievance Decision, which shall include: a. the date the grievance was received; b. a summary statement of the resident's grievance; c. the steps taken to investigate the grievance; d. a summary of the pertinent findings or conclusions regarding the resident's concern(s); e. a statement as to whether the grievance was confirmed or not confirmed; f. any corrective action taken or to be taken by the Facility as a result of the grievance; and g. the date the written decision was issued. A review of the facility-provided grievance forms revealed one without a date, filed by a resident requesting to be provided ginger ale. 395844 Page 5 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Continued review of the grievance form revealed, under the section titled Resolution, revealed no documentation of a staff response to the Resident and the concern presented regarding the request for ginger ale. A review of an additional facility-provided grievance form dated May 31, 2024, revealed documentation of missing glasses. Continued review of the grievance form, under the section titled Resolution, revealed no documentation of the facility's response to the resolution of the grievance. An interview with the Nursing Home Administrator (NHA) on July 17, 2024, at 1:38 PM, revealed staff will be educated on following the facility's policy regarding grievances and resolution. An observation of the facility's bulletin board on July 15, 2024, at 11:04 AM, revealed the name of the facility's Grievance Official (Employee 8). A review of the bulletin board revealed the posting lacked the required contact information for Employee 8 to include the business address (mailing and email) for resident contact. An interview with the NHA on July 17, 2024, at 1:39 PM, confirmed the Grievance Official information only displayed Employee 8's name and phone number at that time. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.29 (a) Resident Rights 395844 Page 6 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and resident and staff interviews, it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman, for two of three resident records reviewed for hospital transfers (Residents 19 and 46 ). Findings include: Review of Resident 19's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hemiparesis left non-dominant side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), stroke (damage to the brain from interruption of blood supply), and epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures). During an interview with Resident 19 on July 15, 2024, at 10:39 AM, it was revealed she was transferred to the hospital in June 2024 for blood in her stool. Review of Resident 19's clinical record documented that she was transferred to the hospital on June 22, 2024, and returned July 1, 2024. Further review of the clinical record failed to document the transfer notice was communicated to or provided to the Resident/Resident Representative. During an interview with the Nursing Home Administrator (NHA) on July 16, 2024, at 2:24 PM, it was revealed that the nurse calls the responsible party to inform of the transfer to the hospital. The Social Worker prints a report of all of the transfers and discharges for the month and sends the report via email to the State Ombudsman's office once a month. During an interview with the NHA on July 17, 2024, at 1:40 PM, it was confirmed that nursing will call the resident representative to inform of the transfer. It was also revealed there is no paper documentation of the transfer notice to the Resident/Resident Representative or communication to the State Ombudsman, or bed hold notice for Resident 19. Review of Resident 46's closed clinical record documented that the Resident was transferred to the hospital on May 23, 2024. Further review of the closed clinical record failed to document the transfer notice was communicated or provided to the Resident/Resident Representative. During an interview with the NHA on July 16, 2024, at 2:24 PM, it was revealed that the nurse calls the responsible party to inform of the transfer to the hospital. The Social Worker prints a report of all of the transfers and discharges for the month and sends the report via email to the State 395844 Page 7 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0623 Ombudsman's office once a month. Level of Harm - Minimal harm or potential for actual harm During an interview with the NHA on July 17, 2024, at 1:40 PM, it was confirmed that nursing will call the Responsible Party to inform them of the transfer. The NHA revealed there is no paper documentation of the transfer notice to the Resident or the Responsible Party, and no communication to the State Ombudsman. Residents Affected - Few 28 Pa. Code 201.14(a) Responsibility of Licensee 395844 Page 8 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of transfer for one of three resident records reviewed for hospital transfers (Resident 19). Findings Include: Review of Resident 19's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hemiparesis left non-dominant side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), stroke (damage to the brain from interruption of blood supply), and epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures). During an interview with Resident 19 on July 15, 2024, 10:39 AM, it was revealed she was transferred to the hospital in June 2024 for blood in her stool. Review of Resident 19's clinical record documented that she was transferred to the hospital on June 22, 2024, and the Resident returned July 1, 2024. Further review of the clinical record failed to document the bed-hold notice was communicated to or provided to the Resident/Resident Representative. During an interview with the Nursing Home Administrator (NHA) on July 16, 2024, at 1:50 PM, it was revealed that Resident 19, wouldn't have been issued a bed-hold notice because the Resident's payor source at time of transfer was Medicaid and it is an automatic 15-day bed-hold. Surveyor asked when that information would've been reviewed with the Resident/Resident Representative, and he stated he would have to investigate it. During an interview with the NHA on July 16, 2024, at 2:24 PM, it was revealed that the nurse calls the responsible party (RP) to inform of the transfer to the hospital and ask if they wish to hold the bed. It was further revealed that the Business Office will follow-up with the RP if a bed-hold is requested to discuss the daily rate cost. During an interview with the Employee 2 (Business Office Manager) on July 17, 2024, at 11:46 AM, it was revealed that Nursing is to complete the bed-hold notice, there is a form. Nursing is to ask the resident or RP if they want a bed-hold a time of transfer, and they should provide the cost of the daily rate at that time. If a family member contacts her regarding wanting a bed-hold, she will discuss the daily rate, otherwise she doesn't follow-up with the transfers. During an interview with the NHA on July 17, 2024, at 1:40 PM, it was confirmed that nursing will call the resident representative to inform of the transfer, ask if they would like to hold the bed and discuss the daily rate, and if a bed-hold is requested, the bed hold form is completed by the nurse. It was also revealed there is no paper documentation of the transfer notice to the Resident/Resident Representative or communication to the State Ombudsman or bed-hold notice for Resident 19. 395844 Page 9 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0625 28 Pa. Code 201.14(a) Responsibility of Licensee Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395844 Page 10 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, clinical record review, policy review, and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one of three residents receiving oxygen therapy reviewed (Resident 40). Findings Include: A review of the facility's policy, titled Care Planning-Interdisciplinary Team, revised September 2013, read, in part, Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. A review of Resident 40's physician orders revealed diagnoses that included chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe) and muscle weakness. An observation of Resident 40, on July 15, 2024, at approximately 11:00 AM, revealed the use of an oxygen concentrator while in bed in her room. A review of Resident 40's interdisciplinary plan of care revealed none developed to address the use of oxygen, goals, and interventions. An interview with the Director of Nursing on July 18, 2024, at 9:28 AM, revealed the facility had not developed and implemented a care plan specific to Resident 40's oxygen use. 28 Pa. Code 211.5 (f) Medical records 28 Pa. Code 211.12 (d) 5) Nursing services 395844 Page 11 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards regarding medication and treatment administration for two of 23 residents reviewed (Residents 24 and 40). Residents Affected - Few Findings Include: Review of facility policy, Administering Medication, revised April 2019, read, in part, medications are administered in a safe and timely manner and as prescribed. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR- recording of physician orders being administered or completed) space provided for that drug and dose. The individual administering the medication initial the resident's MAR on the appropriate line after giving each medication and before administering the next one. Review of Resident 24's clinical record revealed diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms such as depression. Symptoms may include delusions, hallucination, depression, and manic periods of high energy). Review of Resident 24's July 2024 MAR failed to provide documentation for the following on Saturday July 6th, 2024, and Sunday July 14th, 2024, evening shift (the MAR contained blanks, lack of documentation): Atorvastatin at bedtime for hyperlipidemia (high blood lipids), start date October 7, 2023; Famotidine at bedtime for Gastroesophageal Reflux Disease (reflux), start date October 7, 2023; Humalog injection (Insulin Lispro-short-acting insulin) Inject as per sliding scale at bedtime for diabetes mellitus, start date July 5, 2024; Lantus injection (Insulin Glargine- long-acting insulin) at bedtime for diabetes mellitus, start date June 18, 2024; Haloperidol for schizoaffective disorder, start date October 12, 2023; Oxycontin extended release, two times a day for pain, start date November 15, 2023; assess pain level evening shift, start date October 7, 2023; gabapentin for neuropathic pain every 8 hours, start date October 7, 2023 (medication was also not administered July 7 and 14, 2024, at 2:00 PM); accu-checks (blood sugar monitoring) before meals and at bedtime, start date June 26, 2024 (also not monitored July 6th, 2024, nightshift; July 7th, 2024, day shift; and July 14th, 2024, day-evening-night shift). Review of progress notes July 1st through 17th, 2024, failed to document Resident refusal of medication or treatments. Review of Resident 40's clinical record revealed diagnoses that included diabetes mellitus and muscle weakness. Review of Resident 40's MAR during the month of July 2024, revealed on July 14, 2024, the following medications were not shown as administered: Melatonin 5 MG, Omeprazole 20 MG, Glimepiride 4 MG, Magnesium Oxide 4 MG, and Metformin 1000 MG. 395844 Page 12 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0658 Level of Harm - Minimal harm or potential for actual harm Review of Resident 40's progress notes revealed no documentation of a refusal of medications on those dates. During an interview with the Director of Nursing on July 17, 2024, at 11:30 AM, it was revealed that if medications are refused, it should be documented as such on the Medication Administration Record. Residents Affected - Few 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services 395844 Page 13 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided care consistent with professional standards of practice for one of three residents receiving oxygen therapy reviewed (Resident 40). Residents Affected - Few Findings Include: A review of Resident 40's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe) and muscle weakness. An observation of Resident 40, on July 15, 2024, at approximately 11:00 AM, revealed the use of an oxygen concentrator while in bed in her room. A review of Resident 40's physician orders revealed none documenting the Resident's need and use of oxygen. An interview with the Director of Nursing on July 18, 2024, at 9:28 AM, revealed that the facility could not locate an order from the physician for Resident 40's use of oxygen. 28 Pa. Code 211.5 (f) Medical records 28 Pa. Code 211.12 (d) 5) Nursing services 395844 Page 14 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for one of five residents reviewed for unnecessary medications (Resident 24). Findings include: Review of facility policy, Medication Therapy, revised April 2007, read, in part, the consultant pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. Review of Resident 24's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms such as depression. Symptoms may include delusions, hallucination, depression and manic periods of high energy). Review of Resident 24's July 2024 physician orders included: escitalopram for depression, start date October 8, 2024; Humalog injection (Insulin Lispro-short-acting insulin) Inject as per sliding scale at bedtime for diabetes mellitus, start date July 5, 2024; Lantus injection (Insulin Glargine- long-acting insulin) at bedtime for diabetes mellitus, start date June 18, 2024; Haloperidol for schizoaffective disorder, start date October 12, 2023; Oxycontin extended release, two times a day for pain, start date November 15, 2023; assess pain level eve shift, start date October 7, 2023. Further review of Resident 24's clinical record failed to reveal documentation that monthly pharmacy medication reviews were completed. During an interview with Employee 4 (Registered Nurse) on July 17, 2024, at 3:00 PM, it was revealed that the monthly pharmacy medication reviews are not documented in the hard chart/medical record. During an interview with the Director of Nursing on July 17, 2024, at 3:20 PM, it was revealed that the monthly pharmacy reviews are completed monthly off-site, and that the pharmacy should send a list of residents reviewed and any recommendations from the Pharmacist. It was also revealed that she is having difficulty locating documentation to verify the monthly pharmacy reviews were completed. 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3) Nursing services 395844 Page 15 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, staff interviews, and policy review, it was determined that the facility failed to ensure adherence to appropriate labeling of medication for one of two medication carts (front hall cart). Findings include: Review of facility policy, titled Administering Medications, last reviewed June 2024, revealed that the expiration/beyond use date on the medication label is checked prior to administering. When opening the multi-dose medication, the date opened is recorded on the medication container. The policy also stated, Insulin pens are clearly labeled with the resident's name, or other identifying information prior to use. Observation during the front hall medication cart review on July 16, 2024, at 1:35 PM, revealed one Novolog insulin pen (aka insulin aspart-a fast acting insulin) in Resident 1's medication compartment opened, without a resident identifier, or the date it was removed from the refrigerator. This insulin is to remain in the refrigerator until opened for use, and then expires in 28 days after opening. During an interview with Employee 10 (Licensed Practical Nurse) on July 16, 2024, at 1:45 PM, Employee 10 confirmed the Novolog insulin pen should have been labeled with the Resident 1's name and dated when removed from the refrigerator and placed into use. Employee 10 also confirmed that the Novolog insulin expires 28 days after opening. Employee 10 discarded the Novolog insulin. Observation during medication cart review on July 16, 2024, at 1:35 PM, revealed two Lantus insulin (aka Insulin glargine- a long acting man-made insulin) unopened in Resident 1's medication compartment of the medication cart, without a resident identifier, or the date it was removed from the refrigerator and placed in the medication cart. The Lantus insulin both had stickers on to refrigerate, indicating the medication is to be refrigerated until removed to the medication cart, and expires 28 days after removed from refrigeration. During an interview with the Director of Nursing (DON) on July 17, 2024, the DON agreed that policy should be followed and both the Lantus and Novolog insulins should have been labeled with the Resident's name and the date they were removed from the refrigerator. 28 Pa. Code 211.12(d)(1)(2)(5)Nursing services 395844 Page 16 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and in one of one nourishment pantries observed and for one of one meal observed. Findings include: Review of facility policy, Outside Food, revised July 2023, read, in part, food brought in from outside sources will be labeled with content and date and discarded after 5 days. Review of facility policy, Food Storage, revised June 6, 2024, read, in part, open items should be labeled with content and open date. Observation in the kitchen on July 15, 2024, at 9:31 AM, revealed one plastic container with bulk thickener wasn't marked with a label or date. During an interview with Employee 1 (Director of Dinning), revealed the container should be labeled with contents and date. Observation at the three-compartment sink on July 15, 2024, at 9:32 AM, the pH test strips were not available. During an interview with Employee 1, it was revealed that the pH test strips are stored in the office due to the container falling in the water and rendering them useless. It was observed that the test strip expiration date was May 15, 2024. Employee 1 revealed that the facility doesn't have another container of strips, and that the strips shouldn't be expired. Observation in the nourishment pantry on July 15, 2024, at 9:40 AM, the following items weren't date marked or contained a resident identifier: one gallon of chocolate, vanilla, and strawberry ice cream; a half of turkey and cheddar submarine sandwich date marked July 14th; one plastic container of open sushi; and one plastic container with a meatloaf dinner. During an interview with Employee 1 on July 15, 2024, at 9:45 AM, it was revealed that staff shouldn't store personal food items in the nourishment pantry, items should contain a resident identifier, and marked with a date. Observation of tray line service for the lunch meal on July 16, 2024, at 12:05 PM, revealed Employee 3 (Cook) utilized a gloved hand and retrieved a puree plate out of the steamer, unwrapped the plastic wrap from the plate, touched the trash lid to dispose of the plastic wrap, then went back to serving on the tray line touching the corn bread muffins and plate rims with the same gloved hand; without completing hand hygiene. At 12:10 PM, Employee 3 changed his gloves, without completing hand hygiene. Additional observation at 12:12 PM, Employee 3 utilized a gloved hand, retrieved a pasta dinner from the steamer, removed plastic wrap, and touched trash lid with gloved hand to dispose of the 395844 Page 17 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0812 Level of Harm - Minimal harm or potential for actual harm plastic wrap. He did change his glove on his right hand, utilizing his left hand for assistance, without completing hand hygiene went back to serving on tray line touching the corn bread muffins and plate rims. During an interview with Employee 1 on July 16, 2024, at 12:25 PM, it was revealed Employee 3 should've changed his gloves and completed hand hygiene after touching the garbage can lid. Residents Affected - Some During an interview with the Nursing Home Administrator and Director of Nursing on July 17, 2024, at 11:00 AM surveyor discussed food storage and hand hygiene concerns. It was revealed that hand hygiene, including changing gloves, should've occurred. No further information was provided regarding food storage or the expired pH strips. 28 Pa. Code 211.6 Dietary Services 395844 Page 18 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on state regulations, review of facility documents, and staff interview, it was determined that the facility failed to ensure that the Medical Director and Infection Preventionist (IP) was in attendance at least quarterly at the Quality Assurance Process Improvement (QAPI) Committee meetings, and failed to provide sign-in records for QAPI Committee meetings for one of four quarters (first quarter). Residents Affected - Few Findings include: Review of the CFR (Code of Federal Regulations) revealed: §483.75(g) Quality assessment and assurance. §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: The director of nursing services, The Medical Director or his/her designee, At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member, or other individual in a leadership role, The Infection Preventionist, and Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary. Review of QAPI Committee meeting sign-in sheets were provided for the period of November 2023 through June 2024, there was no August 2023 sign in sheet provided. Review of QAPI Committee Meeting sign-in sheets included the following dates: November 8, 2023; February 14, 2024; and May 31, 2024. The Medical Director was not in attendance for the November 8, 2023, meeting. There was no credentialed IP and, therefore, no IP in attendance at any of the meetings provided. During an interview with the Nursing Home Administrator (NHA) on July 18, 2024, at 10:30 AM, the NHA confirmed that the facility failed to make certain that the Medical Director was in attendance at least quarterly at the QAPI Committee meetings for one of the four meetings provided, and failed to provide a sign in sheet for QAPI Committee meetings for one of four quarters (first quarter). The NHA confirmed there was no IP at the meetings. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.18(e)(2)(3) Management 395844 Page 19 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and facility policy review, it was determined the facility failed to maintain a data collection system of surveillance for 10 of 12 months reviewed (October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and July 2024). Residents Affected - Many Findings include: Review of the facility policy, titled Infection Control, last reviewed June 2024, revealed the facility will maintain a monthly line list of residents with infections for trending and outbreak potential, follow-up review of lab data is compared, and a monthly review is completed to identify trends to facilitate infection control surveillance. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and health-care associated infections, to guide appropriate interventions and required reporting, and to prevent future infections. The facility's monthly infection control logs for October 2023 through July 2024 were unable to be provided by the facility. The infection control log book had data entered for July 2023, August 2023, and September 2023, but the rest of the pages for October 2023 through July 2024 were blank. During an interview with the Nursing Home Administrator (NHA) on July 18, 2024 at 11:00 AM, the NHA confirmed the monthly infection control line list data should be maintained but was not being completed because the facility does not have an Infection Preventionist currently trained or credentialed. 28 Pa Code 201.14(a)(c)Responsibility of licensee 28 Pa Code 211.1(a)(c)Reportable diseases 395844 Page 20 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records, the facility's infection prevention and control policy, and staff interview, it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by two of three residents reviewed (Residents 6 and 23). Residents Affected - Some Findings include: A review of the facility policy, titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, last reviewed June 2024, stated, antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of resident antibiotic prescribing practices and facility-wide antibiotic stewardship. The IP (infection preventionist), or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: (1) The organism is not susceptible to antibiotic chosen, (2) The organism is susceptible to antibiotic chosen, (3) Therapy was ordered for prolonged surgical prophylaxis, or (4) Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: (1) Resident name and medical record number, (2) 395844 Page 21 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0881 Unit and room number, Level of Harm - Minimal harm or potential for actual harm (3) Date symptoms appeared, Residents Affected - Some (4) Name of antibiotic, (5) Start date of antibiotic, (6) Pathogen identified, (7) Site of infection, (8) Date of culture, (9) Stop date, (10) Total days of therapy, (11) Outcome, (12) Adverse Events. A review of Resident 6's clinical record revealed that on July 17, 2024, the Nurse Aide reported that the Resident had episodes of incontinence (involuntary loss of urine) and burning during urination. The physician was notified and ordered an urinalysis with culture and sensitivity. The physician also ordered an antibiotic, Cipro 250 mg (milligrams) to be started twice a day for 7 days prior to receiving any urinalysis results. The facility was unable to provide the urinalysis results on July 18, 2024. A review of Resident 23's clinical record revealed a urine specimen was collected July 15, 2024. The progress notes indicate there were no bladder issues. The physician orders stated urinalysis with microscopic culture if indicated. The results of the urinalysis revealed no culture was indicated. On July 16, 2024, the physician ordered an antibiotic, Bactrim DS (double strength) one tab twice a day for 7 days. There was no indication documented for use of the antibiotic. 395844 Page 22 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0881 Level of Harm - Minimal harm or potential for actual harm There was no evidence at the time of the survey of a functioning antibiotic stewardship program that included antibiotic use protocols or a system to monitor antibiotic use to prevent unnecessary antibiotic use. During an interview with the Director of Nursing and Nursing Home Administrator on July 18, 2024, at 11:00 AM, both confirmed that the facility had no IP or antibiotic surveillance tracking form since September 2023. Residents Affected - Some 28 Pa. Code 211.12 (d)(1)(2) Nursing services 28 Pa. Code 211.10 (a) Resident Care Policies 395844 Page 23 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on staff interviews and state regulations, it was determined that the facility failed to have an Infection Preventionist (IP) that completed an approved program for specialized training in infection prevention and control. Findings include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(4) stated, The facility must designate one or more individual(s) as the Infection Preventionist(s) (IP(s) who are responsible for the facility's IPCP (Infection Prevention Control Program) that have completed specialized training in infection prevention and control. During an interview with the Director of Nursing (DON) on July 15, 2024, at 10:00 AM, Employee 4's (Registered Nurse) IP credentials were requested. The DON confirmed Employee 4 is currently doing the modules that are required to obtain certification for the IP position. The DON also informed the surveyor that no Infection Control data has been tracked since September 2023. 28 Pa. Code 201.18(b)(2) Management 395844 Page 24 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents were offered influenza and pneumococcal as required for two of five residents reviewed (Residents 33 and 41). Residents Affected - Some Findings include: Review of facility policy for influenza, pneumococcal, and COVID 19, last reviewed June 2024, indicated that before any of the vaccine is received, the resident or their legal representative shall receive information regarding risks and benefits of the vaccine. The policy also revealed that consents and refusals would be documented in the resident's clinical record. A review of Resident 33's clinical record on July 18, 2024, confirmed that Resident 33 was admitted to the facility on [DATE]. The clinical record revealed Resident 33 refused the influenza in 2022 and 2023. There was no record of pneumococcal vaccine for Resident 33. Further review of the clinical record revealed no education on risks and benefits, and no consent or refusal documentation was entered into the clinical record in the nurses' or physician notes. A review of Resident 41's clinical record on July 18, 2024, confirmed that Resident 41 was admitted to the facility on [DATE]. There was documentation to confirm that the Resident was offered the influenza vaccine, but did list influenza vaccine was last administered in 2021. Further review of the clinical record revealed no education on risks and benefits, and no consent or refusal documentation was entered into the clinical record. During an interview with the Director of Nursing on July 18, 2024, at 11:00 AM, she confirmed that there was no documentation of risks or benefits and no documentation of consents and refusals for these Residents, and agreed that policy should be followed. 28 Pa. Code 201.18(b)(1) Management 395844 Page 25 of 26 395844 07/18/2024 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy, and interview, it was determined that the facility failed to ensure that residents were offered any current COVID-19 vaccinations as required for four of five residents reviewed (Residents 1, 12, 33, and 41). Findings include: Review of facility policy for COVID 19, last reviewed June 2024, indicated that before any of the vaccine is received, the resident or their legal representative shall receive information regarding risks and benefits of the vaccine. The policy also revealed that consents and refusals would be documented in the resident's clinical record. The physician will assess the resident for any contraindications to receiving the vaccine. A review of Resident 1's clinical record on July 18, 2024, confirmed that Resident 1 was admitted to the facility on [DATE]. Further review of the clinical record revealed no historical (past) COVID-19 vaccine or any documentation to confirm that the COVID-19 vaccine was offered by the facility since admission. There was no consent or refusal documentation for COVID-19 vaccine in the clinical record. A review of Resident 12's clinical record on July 18, 2024, confirmed that Resident 12 was admitted to the facility on [DATE]. Further review revealed that an historical COVID-19 vaccine was given in 2021, but there was no documentation to confirm that any current COVID-19 vaccine was offered by the facility since admission. Further review of the clinical record revealed no education on risks and benefits, and no offer or refusal documentation was entered into the clinical record. A review of Resident 33's clinical record on July 18, 2024, confirmed that Resident 33 was admitted to the facility on [DATE]. The clinical record revealed Resident 33 refused COVID-19 dose 1. Further review of the clinical record revealed no education on risks and benefits, and no consent or refusal documentation was entered into the clinical record in the nurses' or physician notes. A review of Resident 41's clinical record on July 18, 2024, confirmed that Resident 41 was admitted to the facility on [DATE]. Further review revealed that an historical COVID-19 vaccine was given in 2021, but there was no documentation to confirm that any current COVID-19 vaccine was offered by the facility since admission. Further review of the clinical record revealed no education on risks and benefits, and no consent or refusal documentation was entered into the clinical record. During an interview with the Director of Nursing on July 18, 2024, at 11:00 AM, she confirmed that there was no documentation of risks or benefits and no documentation of consents and refusals for these Residents, and agreed that policy should be followed. 28 Pa. Code 201.18(b)(1) Management 395844 Page 26 of 26

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Citations

19 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0575GeneralS&S Dpotential for harm
F575 - The facility must post, in a form and manner accessible and understandable
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
0577GeneralS&S Dpotential for harm
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
0578GeneralS&S Epotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0582GeneralS&S Dpotential for harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0585GeneralS&S Epotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0623GeneralS&S Dpotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0625GeneralS&S Dpotential for harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0658GeneralS&S Dpotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0868GeneralS&S Dpotential for harm
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Epotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0882GeneralS&S Fpotential for harm
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
0883GeneralS&S Epotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0887GeneralS&S Epotential for harm
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

FAQ · About this visit

Common questions about this visit

What happened during the July 18, 2024 survey of ELIZABETHTOWN NURSING AND REHABILITATION?

This was a inspection survey of ELIZABETHTOWN NURSING AND REHABILITATION on July 18, 2024. The surveyor cited 19 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ELIZABETHTOWN NURSING AND REHABILITATION on July 18, 2024?

Yes, 19 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a stateme..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed September 21, 2026. If you believe any information is inaccurate, report it here.

Health inspection·July 18, 2024